Community Health Partnership
[pic] Clinic: ___________________ ( Quest Diagnostics #________
Address: ________________ (Clinic site number for Quest use)
________________________ ( PENRAD Imaging (plain x-rays only)
Phone: __________________
Fax: ____________________ ( CATCH # ________________
(CATCH Coordinator assigns number)
Diagnostic Lab, Imaging, Specialist Referral, and Eligibility Form
I. Client’s Release of Information to CATCH care teams and clinical sites:
I have previously signed this clinic’s or care site’s privacy assurance statement, and I now agree to allow my information to be exchanged between CATCH care teams and clinical sites that are coordinating my care. _____Client Initials
Client’s Name _________________________________________ DOB _________________________
Home # _____________________ Work # __________________ Cell # ________________________
Address______________________________________________ Email: ________________________
II. Ordering or Referring Clinician’s Prescription / Notes:
1. Diagnosis: ( HTN I10 ( NIDDM E11.8 ( Hypothyroidism E03.9
( Hyperlipidemia E78.2 ( Other: _______________________________________________
2. Type(s) of referral(s) requested:
a. Lab: ( Comprehensive metabolic panel (CMP) ( Basic metabolic panel
( CBC ( Hemoglobin A1C
( TSH w/reflex FT4 ( Strep Screen
( Lipid Panel (fasting) ( Strep Culture
( Urine Culture ( Sedimentation Rate
( Drug Level: ( Lithium ( Depakote ( Phenytoin ( Tegretol
( Other: ________________________________________
b. QUEST Diagnostics: ( (Please follow your current Quest Diagnostics process for test ordering.)
c. Imaging: ( Plain X-ray_____________________________________________
( ** Specialty Tests ________________________________________
d. **Specialty Referral:
Physician / Specialty ___________________________________________________
____________________________________________________________________
3. Reason for diagnostic referral or consult: __________________________________
_______________________________________________________________________
Ideal timeframe lab/x-ray/test to be performed (#days, #weeks) _____________________________
III. _________________________________________________________ Date _______________
Printed Name and Signature of the Ordering Clinician
IV: Results: ( Please fax results to: _________________________
V: Eligibility: ( Eligible for CATCH Services; see page 2 for details.
**Needs prior authorization from CATCH Medical Director
(include referral, pages 1-2, and clinical notes)
Page 2 Client name: _________________________ DOB: _________________
Clinic site use this form to determine if a client qualifies for CATCH services. Send copy to CATCH Coordinator.
CATCH serves uninsured or underinsured residents of the Pikes Peak region who are at or under 200% of the Federal Poverty Level (FPL) and do not qualify for Medicaid or other insurance.
Step 1: Determine if you are within the income guidelines for CATCH services.
Family size: ____ Monthly income before taxes: $___________ OR Annual income before taxes: $___________
NOTE: If your income is lower than indicated in the box for your family size, you will need to apply for Medicaid.
If your income is higher than indicated in the box for your family size, you are not eligible to receive CATCH services, but please consult with Clinic staff about other resources.
Family Size |
1
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2
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3
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4
|
5
|
6
|
7
|
8
|
9
|
10
| |
Monthly Income |$1385-2082 |$1875-2818 |$2365-3555 |$2854-4292 |$3344-5028 |$3834-5765 |$4324-6502 |$4814-7238 |$5293-7975 |$5772-8712 | |
Annual Income |$16,612-24,980 |$22,490-33,820 |$28,369-42,660 |$34,248-51,500 |$40,126-60,340 |$46,005-69,180 |$51,883-78,020 |$57,762-86,860 |$63,641-95,700 |$69,519-104,540 | | Based on 2019 CHP+ Income Guidelines 133%-200% FPL
Step 2: Determine your insurance status.
Are you covered by any of these programs? Check all that apply.
( Medicaid ( Medicare; Part ____________ ( Private Insurance
( Workplace-sponsored insurance ( CICP; Level _______ ( Other ____________________
( If no boxes are checked, I declare I am not insured or not eligible for insurance.
Please provide copies of these documents to the Clinic site for their CATCH eligibility records:
( Proof of local residence - Colorado driver’s license, utility bill with address, lease agreement, voter registration card, etc.
( Income proof - last 3 months pay stub for all members in household, Unemployment Benefits, Child Support, Retirement/Pension, Social Security Benefits, SSI Survivor Benefits, SSDI Veterans Benefits, Veteran Widow, Dividends/Interest, Alimony, Loans/Gifts, Workers’ Compensation, Disability Benefits, Financial Aid, Public Assistance, Railroad Retirement, Rental Income, In-Kind Income (working for rent), Other Cash Received Monthly
My signature, below, designates that income and insurance information provided is true and accurate.
Client Signature____________________________________ Date_____________________
Clinic Signature____________________________________ Date_____________________
***************************************************************************************************************************************
CLINIC STAFF PLEASE COMPLETE FOR CATCH ELIGIBILITY PURPOSES
Medicaid Verification:
Call CCHA Member & Provider Support at 719-598-1540 for Medicaid verification information
Medicaid: ( Yes ( No Medicaid ID number: _____________________
Spoke to Service Rep (name): _______________________________ Date: ______________
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